FNPII Adult Cardiac

SBP > 140 and DBP >90 based on the average of two or more seated BP readings on two or more office visits.

Pre-HTN = SBP 120-139 / DBP 80-89

Stage 1 HTN = SBP 140-159 / DBP 90-99

Stage 2 HTN = SBP >=160 / DBP >= 100

New onset of DBP after the age of 60.  Consider renovascular disease.  

When EITHER SBP >=140 or DBP >=90

Doubles the risk of cardiovascular disease in 40-70 year olds.

Young onset of HTN <30 or older onset >50.

• Obesity, obstructive sleep apnea, renovascular disease, chronic steroid therapy, Cushing's syndrome, primary hyperaldosteronism, pheochromocytoma, coartation of the aorta, thyroid disease, parathyroid disease, and excess ETOH intake.
• Drugs: NSAIDS, Cox-2 Inhibitors, Diet pills, oral contraceptives, erythropoietin, cocaine, amphetamines, steroids, tacrolimus, cyclosporine, ephedra, licorice, smoking, chewing tobacco.  

SBP>=180 / DBP >= 110 and evidence of acut target organ damage. 

• Papilledema, hemorrhages, or exudates on funduscopic exam.
• Change in mental status or neurological deficts on exam.
• EKG consistent with myocardial ischemia or infarction.
• Chest xray showing heart failure or aortic disection.  
• Renal dysfunction evidenced by hematuria, proteinuria, and elevated serum creatinin. 

Left ventricular hypertrophy.

An S3 gallop, pulmonary crackles, JVD, and periferal edema.

Age, gender, postmenopausal status, diet, activity level, ETOH, caffeine use, smoking, dyslipidemia, diabetes, family history and  current meds. 

When too much calcification in the vessel wall does not allow the cuff to proper compress the vessel wall. 

Left atrial enlargement.  Echo is most usefull in detecting increasing Left ventricular thickness.

SBP >160 with normal DBP 86 or less as a consequence of atherosclerocitic thickening of the vessels.  Effects nearly half of all adults >65 y/o.

• Lifestyle modification.
• No meds unless compelling reason. 

• Lifestyle modifications
• Thiazide type diuretic

Non-diabetic < 130/90

Diabetic / renal < 120/80

An agent with once daily dosing with atleast 50% of its action in the last 12 hours.

Initiating therapy with two agents one of which is thiazide diuretic. 

After goal BP is achieved, otherwise patient risks hemoragic stroke. 

Schedule a repeat BP check and electrolyte check 2-3 weeks. Serum Potassium and creatinine levels should be checked several times per year. 

150 mg / dL.

Less than 200 mg /dL

Trigylcerides are the large lipid molecules formed from dietary fats.

Increased BMI, elevated systolic BP, Hyper triglycerdemia, hyerglycemia, and low levels of HDL-C.  Any three of the above qualifies the patient as metabolic syndrome. 

Liver enzymes 3X normal.

Initially at 6-12 weeks, then every 6 months.

Because it may indicate a significant drop in cardiac output during the episode of pain causing decreased perfusion to the skin.

SOB that begins when the patient is in a supine position.

SOB that occurs 2 to 4 hours into sleep.  Concurrent with redistribution of body fluids and a subsequent rise in left atrial pressure.  

The person awakens suddenly with SOB, stands or sits up for 10 to 30 minutes to reset.

NOT an emergency.

LVH

When a the average of at least two seated BP measurements on at least two or more vistits exceeds 90 DBP or 140 SBP.

SBP > 160 with a normal DBP.  Occurs in 1/2 of adults over 65 y/o.  Due to atherosclerotic thickening of the vessels. 

• ACEI in the presence of:
• Heart failure
• MI Limits cardiac remodeling!
• Diabetes
• Renal insufficiency
• NOT in Pregnancy!

• Location:
• Over Lung area

• Charactaristics:
• Stabbing; may be cyanotic, dsypnea, or cough with hemoptysis; sudden onset

• Worse with inspiration
• Better with analgesics

• Location: 
• Retrosternal, upper abdom, or epigastric.  May radiate to back neck and shoulders.

• Charactaristics:
• Excruciating, tearing, may be accompanied by BP diffences betweeen L arm and right arm.

• Nothing makes it worse
• Relieved by analgesics.

• Location:
• Across chest; may radiate to jaw, neck, arms and back.

• Charactaristics:
• Pressure, burning, aching, tightness; may be accompanied by SOB, diaphoriesis, weakness, anxiety; nausea; sudden onset; last 1 to 2 hours.

• Aggravated by exertion and anxiety
• Relieved by NARCOTIC analgesics - Morphine

• Location:
• Anywhere in the chest.

• Charactaristics:
• Dull or stabbing pain, usually accompanyied by hyperventilation or breathlessness, sudden onset, may last less than a minute or for several days.

• Aggravated by increased resp. rate, stress and anxiety.
• Relieved by slowing of resp rate, stress relief. 

• Location:
• Anywhere in the chest.
• Charactaristics:
• Sharp, continuous or gradual; chest may be tender to the touch;  gradual or sudden onset.

• Aggravated by: Movement, palpation
• Relieved by: Time; analgesics or heat application

L atrium

Prevent stroke

Asthma or COPD

The largest CCB family is the dihydropyrines. Act primarilily on the arterioles.

• Verapamil and dilitiazem are CCBs but from different families. 
• Act on arterioles AND the heart.  Verapamil increases digoxin levels by 60%.

Useful in treating Raynauds.

Gout and DM

• Sleep apnea
• Drug-induced or related causes
• Chronic kidney disease
• Primary aldosteronism 
• Renovascular disease
• Chronic steroid therapy and Cushing’s syndrome
• Pheochromocytoma - tumor of adrenal gland - results in too much epi and nor-epi
• Coarctation of the aorta
• Thyroid or parathyroid disease 
•      Hyperthyroid - heart beats faster - incr BP
•      Hypothyroid - incre stiffness vasculatur Diastolic HTN.

• Routine Tests
• • Electrocardiogram 
• • Urinalysis 
• • Blood glucose, and hematocrit 
• • Serum potassium, creatinine, or the
• corresponding estimated GFR,     and
• calcium Lipid profile, after
• 9- to 12-hour fast, that includes high-density and  low-density lipoprotein cholesterol, and triglycerides 

• Optional tests
• • Measurement of
• urinary albumin excretion or albumin/creatinine ratio 
• More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

CCB

Contraceptives - yes

HRT - No

• Thiazide diuretics should be used cautiously in gout or a
• history of significant hyponatremia.

• BBs should be generally avoided in patients with asthma,
• reactive airways disease, or second- or third-degree heart block.

ACEIs and ARBs are contraindicated in pregnant women or those likely to become pregnant.

• ACEIs should not be used in individuals with a history
• of angioedema.

Aldosterone antagonists and potassium-sparing diuretics can cause hyperkalemia.

• •Factor V Leiden mutation
• •Protein C deficiency
• •Protein S deficiency
• •Anti thrombin III deficiency
• •Homocycteinemia
• •Prothrombin gene mutation

90% PE come from DVT.

• •Referral to hospital or vascular surgeon
• •LMWH-Dalteparin/Fragmin or enoxaparin BID
• •Warfarin overlapped
• •Continue warfarin 6 months to lifetime

• •Thrombus and inflammation of the superficial veins.
• •Greater or lesser saphenous veins

• •Hardening of vein
• •Redness, warmth and tenderness over vein
• •No significant edema of extremity
• •SVT is a clinical diagnosis

HMG CoA Reductase Inhibitors (Statins)

Primarily decrease LDL by binding to bile acids in the intestinal tract.

GI upset is common

• •Gemfibrozil  600 mg BID
• •Fenofibrate  200 mg QD
• •Clofibrate  1000 mg BID
• •Fenofibric  45-135 mg

•Ezetimibe  10 mg  daily

• Angina syptoms are worse with:
• Patient activity, heavy meals, cold weather, and resolve with rest and nitro.

• Unstable Angina 
• •Inc. in frequency of CP
• •Inc. in severity of CP
• •Inc in duration of CP
• •Chest Pain at rest > 20 min < 30 min
• Not relieved by rest and nitro
• •CP is provoked by a lower level of Pt activity

• •CP awakens the
• patient at night

77% having MI

Post MI troponin levels maybe elevated for 2 weeks.

33% of patients with unstable angina have elevated troponins but NORMAL CKMB.

• LDH ( lactase dhydrogenase)
• •Found in heart muscle, RBC and kidney
• •With acute MI, LDH becomes detectable by 12 hours post
• CP, peaks 24-48 hours and remains 10-14 dys following MI
• •Can be used to help R/O MI when symptoms present > 24 hrs (along with Troponin).

• • Other labs to consider
• •CRP (C Reactive Protein)- acute inflammation
• •BNP- substance which is secreted from the ventricles in
• response to pressure d/t CHG
• •Homocysteine- inflammation
• •CBC with diff (in anemia)- lack hemoglobin to transport O2
• •BMP
• •Liver panel/ lipid panel/ TSH (hyper)/Glucose

• Waste producte of RBC breakdown.
• Unconjugated, AKA Free, AKA indirect must go to liver to be broken down into direct or watersoluable Bili to be excreated. 

Elevated indirect bilirubin levels indicate prehepatic jaundice, such as hemolytic jaundice, or certain types of hepatic jaundice involving inability to conjugate bilirubin.

Elevated direct bilirubin levels indicate other types of hepatic jaundice, such as in viral or alcoholic hepatitis, or posthepatic jaundice, as in biliary obstruction.

•Elevated uncojugated bili due to neonate’s inability to clear bili

•Elevated dependant on age and rise of bili

•>30 = brain damage

• •Found in the kidneys, biliary
• tract, epithelium, intestinal mucosa and the placenta

•Determines liver and bone disorders

• •Significantly elevated in bile duct
• obstruction/ bile duct disease

• •Enzyme produced in bile ducts
• •Alcohol causes elevation
• –Inc. heavy drinkers absence liver disease
• –Detects presence alcohol even with small amt. ingested
• –Important evaluation and management of alcoholism
• * GGT also used to differentiate
• liver from skeletal disease when the ALP is elevated

•Increases seen with leukemia or Hodgkin’s

2-6% of leukocyte count

Phagocytic cells that remove debris from body

• Increase tests for:
• TB, leprosy, lipid storage dz, ubacute bacterial endocarditis, monocytic leukemia, malaria, RMSF

Decreased in RA, HIV

• •Depressed T’s
• •Elevated P’s
• •Cardiac irritability
• •Neuromuscular changes (tetany, coma)

• •Peaked T’s
• •Flattened P’s
• •Cardiac arrest
• •Bradycardia
• •Nueromuscular weakness, tremors, flaccid paralysis

• •Anorexia
• •N & V
• •Muscle cramps
• •Seizures
• •Lethargy
• •Apathy, confusion, decreased sensation

• •Diabetes insipidus
• •Tracheobronchitis
• •Primary aldosteronism
• •Coma
• •Cushings

• •Hyperparathyroidism and cancer most common
• reason.
• •Prolonged immobilization
• •Excessive Vit. D intake
• •Paget’s dz
• •8.6-10mg/dl (nl CA); 4.65-5.28
• (ionized)
• •>13 cardiotoxicity, arrythmias and coma

• •Pseudo (reflection of low albumin)
• •Hypoparathyroidism (usually due to accidental surgical removal of the glands, irradiation,GI disorders
• •Hyperphosphatemia (laxitives, renal failure)
• •Renal failure
• •Vit D deficiency
• •< 6 may produce tetany and convulsions

• •Hyperparathyroidism
• •PTH producing tumors
• •Increased Vit D intake

• •Hyperventilation (with Tx
• of ICP)
• •HCO3 admin in metabolic acidosis
• •Acute pancreatitis
• •Hypoparathyroidism 
• •Vit D deficiency
• •TSS
• •Fat embolism
• •>7 coma

Episodes unrelated to activities that increase oxygen demand. Cyclic often occurs during sleep, intensifies quickly and lasts longer than stable angina. S/S palpitations, syncope, bradycardia. Relief: Exercise

Diabetics

Dysrhythmias secondary to hypokalemia due to diuretic use.

Anorexia, nausea, vomitting, visual disturbances, blurred vision, yellow tinge to vision, appearance of halos around dark objects.

Within 3 hours; 30 minutes best.

• •If severe send to ED/ cardiologist
• •Start diuretic therapy: mild (HCTZ); severe (loop diuretics with K replacement)
• •Ace inhibitors for all LV systolic dysfunction
• •Beta Blockers (decrease cardiac work load & reduce sympathetic stim, decrease afterload)
• •Weigh q day
• •Na restricted diet
• •Consider inotropic agents: digoxin, IV Tx: Dobutamine, Amrinone, Nesiritide

In a branch of the middle cerebral artery.

Grade 1Generalised arteriolar constriction - seen as `silver wiring` and vascular tortuosities.

Grade 2As grade 1 + irregularly located, tight constrictions - Known as `(AV) nicking` or `AV nipping`

Grade 3As grade 2 + with cotton wool spots and flame-hemorrhages

Grade 4As above but with swelling of the optic disk (papilledema)